Background: The incidence of Mycobacterium tuberculosis in hemodialysis (HD) and renal transplant (RT) patients in developing countries is high. With the resurgence of tuberculosis in the US, insights gained in the diagnosis and treatment of this infection in HD and RT patients in developing countries should be valuable to physicians in the West. Methods: A retrospective study of 40 cases of tuberculosis, 24 in HD patients (24/177, 13.6%) and 16 in RT patients (16/109, 14.7%) diagnosed over a period of 21 months in one center. Results: The clinical features, diagnostic procedures, and management dilemmas of this group of patients are described in this report. Diabetes mellitus was the most common associated disease in both groups of patients. Fever, the most common presenting sign, was persistent low grade in 66.6% of HD patients and high intermittent in 56.2% of RT patients. Fever of unknown origin was only seen in RT patients. Pulmonary involvement was most common in both groups, presenting either as infiltrates or effusions. Tuberculous peritonitis was seen only in HD patients (33.3%). Eight HD patients were treated for tuberculosis for variable periods prior to transplantation, 4 of whom had less than 6 months of therapy. None had a recurrence of tuberculosis after transplantation. Because of the known cyclosporin-lowering effect of rifampicin resulting in an increased cost of immunosuppressive therapy, 13 patients were treated successfully with rifampicin-sparing therapy. Conclusion: Tuberculosis should be included in the differential diagnosis of fever in HD and RT patients, especially if fever is of unknown origin in the RT patient. M. tuberculosis in the renal transplant patient can present with high intermittent fever. Partial treatment of tuberculosis is sufficient prior to renal transplantation but treatment should be continued to completion after transplantation. If the cost of immunosuppressive therapy is prohibitive because of rifampicin, rifampicin-sparing antituberculosis therapy can be successfully employed in RT patients.
Sensitization has a significant negative impact on the outcome of haploidentical LRD kidney transplants. Sensitized potential recipients and their potential donors should be aware of this in arriving at informed decision-making for transplantation. These patients may benefit from more sensitive cross-match testing, more intense or more novel immunosuppression, or immunomodulation to modify their immune responsiveness.
The reactivation of mycobacterium infection in renal transplant recipients in developing countries is a common therapeutic dilemma, especially in those patients receiving cyclosporin immunosuppression. The inclusion of rifampicin in the antituberculosis protocol increases the risk of precipitating acute allograft rejection due to its interaction with cyclosporin and also increases the financial burden. We successfully treated 16 patients who developed mycobacterial infection post renal transplant with a rifampicin sparing antituberculosis drug regimen. Pyrexia of unknown origin was the most common manifestation observed and a therapeutic trial with antituberculosis drugs is justified. De novo diabetes mellitus appears to be an added risk factor and increases the susceptibility to mycobacterial infection.
Background We aimed to formulate a consensus for the therapeutic utilization of antibiotics based on contemporary evidence and the real-world experiences of the clinicians at the forefront of the care of patients with urinary tract infection (UTI). Methods We developed customized technological response system for mapping exercise and panel of eminent specialists was convened. Prior consent was obtained, and the weblink of the questionnaire was provided. Sub-expert nationwide panel (n=397), across India (PRISM Survey group), rated their level of agreement with 11 questions with each item on a five-point Likert scale and 5 objective response questions. The consensus was pre-defined if the weighted mean score for the Likert scale was >100. Data were statistically analysed by GraphPad software version 9.5.0. Results The mean years of experience were 9.2 years (SD ±10, 95% CI 8.2–10), and cumulative clinical experience was 3669 person-years. The predominant clinical practice setting of the respondents was a public hospital (58.6%). The highest agreement score in the decreasing rank order (of adjusted weighted mean score) for UTI were: antibiotic resistance is a major challenge (126.1), oral fosfomycin-based regimens are effective against MDR pathogens (123.4), is a good option for bacterial biofilm reduction (121.7), the potential to manage recurrent lower UTI (121.6), oral fosfomycin along with nitrofurantoin is been useful to manage MDR UTI (106.8), nitrofurantoin and fosfomycin are chosen as empirical treatment (103.7), fosfomycin has stood the test of time (120.2). Adjusted mean response scores (±SD, 95% CI) for consensus were: agree (73±9.4, 95% CI 66 to 79) followed by strongly agree (32±13, 95% CI 24 to 41), neither agree nor disagree (13±4.9, 95% CI 9.8 to 16), disagree (−6.5±4.7, 95% CI −9.7 to −3.4), strongly disagree (−0.86±0.9, 95% CI −1.5 to −0.26). Conclusions In the era of MDR UTI, time-tested oral fosfomycin and nitrofurantoin can improve management of UTI without increasing the complexity.
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